What is it about paramedics working in general practice that works (or doesn’t work)? A rapid realist review.

Problem

General practice in the UK is under pressure to meet a growing demand and there is a lack of GP workforce to meet this need. Paramedics are one group of staff being used to provide additional resource. Little is known about what models of paramedic working are in place in UK general practice, and how variation between these models may impact on the success of the paramedic role in this setting. This realist review aimed to develop initial programme theories to explore how the role of paramedics and models of working in general practice may impact on patient, practice and paramedic outcomes in different contexts. This review is the first stage of a realist evaluation which will test these theories at case sites across England to determine the clinical and cost effectiveness of the role (NIHR:132736).

Approach

The review comprised:1) Empirical literature searches (databases n=8; date limited to after 2002)2) Grey literature searches (search engines n=2; healthcare websites n=6; social media websites n=2; reference list searches n=4)3) Semi-structured interviews with system leaders involved with the implementation of paramedics in general practice (n=8)4) Stakeholder event with professionals and members of the public to clarify areas of priority and identify any gaps in theoretical development. (n=22)Data sources were first analysed separately and then amalgamated using a realist approach that explored the data for novel or causal insights.

Findings

The empirical search identified 2235 records which were screened on title and abstract, and 32 were included. The grey data search identified 232 sources (outside the social media searches), and 87 contained relevant insights. Data from these sources were synthesised with the interview analysis and consensus event analyses into a single narrative document which grouped a set of initial programme theories into eight areas: [1] Paramedic scope of practice; [2] Education, qualifications and titles; [3] Supervision and communication; [4] Role boundaries and workload; [5] Paramedic prescribing; [6] Patient experience of the role; [7] Rotational models of working and [8] Beyond general practice: impact on secondary care.The search confirmed there are a wide variety of models of paramedics working in general practice in operation throughout the UK. The success of models varied depending on how mature and embedded the paramedic service was and according to the eight theory areas.

Consequences

These findings provide a framework for making future recommendations about successful implementation of paramedics working in general practice. Key considerations will pertain to how and why service models impact on: patient clinical outcomes, safety, and health service experience; GP and practice workload and satisfaction, and health service resource use.